"It was a plague so deadly that if a similar virus were to strike today, it would kill more people in a single year than heart disease, cancers, strokes, chronic pulmonary disease, AIDS and Alzheimer's disease combined." Between 20 million and 100 million people worldwide died in the 1918 flu pandemic, but for years afterward this deadliest plague in history was almost completely forgotten. Histories and even medical texts rarely mentioned it. This disconnect between the flu's devastation and its obscurity is the starting point for [Gine] Kolata's incisive history. She explains how the plague spread, covers the various speculations about its causes and origins and gives an account of the search to retrieve a specimen of the virus strain once genetic science had advanced enough to unravel the virus's mysteries. Tissue samples from an obese woman buried in the permafrost of Alaska and from two soldiers who died in army camps preserved by the Armed Forces Institute of Pathology in thumb-sized bits of paraffin prove to be the last remaining sources of the 1918 strain... Could such a deadly flu appear again?

48 comments:

Your book was published in 2001 and was outdated in 2005, when scientists not only recreated the world's most dangerous virus, they further published the genome and detailed instructions that would allow somebpdy with a gene splicing machine to make it themselves. Ethicists have been debating both sides of this for years now.

This was so bad that it was the same as having two years of the plague returned to earth, especially in urban environments. Since science and engineering was the new most respected powers around, every one justtook the blame on themselves for Bad Hygiene, like not wasing your hands. In truth the losses of life were not anyones fault, unless you pointed a finger at the world travel boom from science and engineering. The little viruses just wiped out their hosts and ran out of steam.

The not-nearly-as-bright-as-they-think-they-are politicians and journalists keep focusing on influenza. What is unusual about the 1918 pandemic is that it is the only known case of an influenza virus that killed via a cytokine storm. There are lots of viruses that kill that way -- not many years ago there was an outbreak of Hanta virus in the Southwest. Since people got on top of it right away it never had the spread that the 1918 flu pandemic had. (Suspicious person that I am, I also believe that east coast and left coast journalists weren't much interested in a disease that predominantly killed young, healthy Native Americans.)

There are lots of viruses that kill in nasty ways and that could get into the United States. Virus Hunter by C. J. Peters has a description of a person dying from Venezuelan Equine Encephalitis (VEE) that will make you want to stay well north of that country forever.

The unusual thing about this particular kind of disease is it's your immune system that actually kills you as it goes crazy trying to rid your body of the virus. So people with aggressive immune systems, i.e. healthy people, are the ones most likely to actually die instead of just getting sick.

Uh-oh. In answer to Ann's question, could it reemerge, I was just going to say, let's not chance it.

In the 1918 outbreak, did people die of the flu itself or the secondary infections, like pneumonia? They had no antibiotics, so I'm telling myself that one would have a much better chance now to survive it.

Lastly, I think Palladian is correct. If you look at the flu map on Instapundit, the CA cases clearly are close to the Mexican border. It's not a tourism-based outbreak. It's proximity to the source.

@PatCA, why are you so worried about the flu living in labs. There are smallpox samples living in labs. No one has been vaccinated against it for years, and many people can't be vaccinated against it anymore. Smallpox is an even worse way to die than influenza.

As to your question, the data indicates that the people who died did so directly from the disease. Go to the link in my 10:27 comment or Google "cytokine storm". That was one of the things that was so scary about the 1918 pandemic -- it preferentially killed the young, strong and healthy. Also how quickly it killed -- people woke up with vague flu-like symptoms and were dead by mid-afternoon. The British military recorded cases of soldiers showing up for morning sick call and appearing to be healthy enough to be sent back to barracks, but being dead before sundown.

But as I said above, (1) there are lots of viral diseases that kill by cytokine storms; (2) influenza doesn't normally kill that way; and (3) based on the available information from Drudge it appears that this flu is a normal sort of flu -- Tamiflu is effective against it, and it preferentially kills the old and the weak.

Like Reston Ebola, we dodged another bullet.

Just thought I'd offer something to comfort you on a lovely Sunday morning.

Big Mike - There are lots of viruses that kill in nasty ways and that could get into the United States..

Yes, there are, but no virus that nasty, fortunately, has the contangeous capacity of flu. That is why flu is such a concern. Other bugs generally cause "outbreaks". Flu is something that goes global easily from ready human-to-human transmission in certain strains.

Epidemiologists have tracked all sorts of flu types and their pattern of spread since the 1918 one hit us. Generally, the trend is "faster and faster" as global population increased 5-fold since 1918 and transportation anywhere is now a function of hours, not days or weeks.

Even the Black Plague, and the deadly smallpox pandemic in the New World - took decades to spread. The 1918 Flu took 2 months, when much of the world was only linked by shipping traffic and much land travel was by foot or animal.

And significant parts of the world excaped the 1918 Flu's deadly efects by simple remoteness or by planned quarantine. They eventually got it, but after the 1918 strain had mutated again and become less virulent. The death rates from it in Australia and NZ when they got hit 4 months after Europe did - were less than in France or Russia.

======================PatCA - In the 1918 outbreak, did people die of the flu itself or the secondary infections, like pneumonia? They had no antibiotics, so I'm telling myself that one would have a much better chance now to survive it..

My understanding is that the pulmonary edema and toxins released by high fever were symptoms of the immune systems going haywire from the 1918 Flu. There were no opportunistic secondary infections by bacteria. In reading about the 1918 Flu though, in The Atlantic, and the deadly avian flu that is not-yet mutated to ready human-to-human transmission intensive medical care in treating the symptoms - draining lungs, administrering immunosuppressants, putting patients on oxygen, keeping them from dehydration - had some measure of life-saving results.

Unfortunately, in our "rights - based" society, if something is deadly enough...doctors and nurses and other hospital staff may elect to bolt. My grandfather was a doctor who had his own Mom killed in the 1918 Flu, a year after he was born. Plus some aunts and uncles, all in Chicago, he said. What was interesting was that in Chicago some did bolt when it got bad and nurses and doctors were heavily impacted themselves - one hour treating, the next hour dying alongside their former patients. He said that a lifetime stigma affixed to those that "deserted their posts". Back then, it was simply expected that doctors and nurses had an obligation to duty, to the public, when they entered the profession.

In short, if a future pandemic is bad enough, don't bank on the "miracles of American medicine" to save you. The people you count on may just be well, well gone from the hospital.

Retrospective analysis suggests that a high proportion of 1918-19 deaths are attributable to bacterial pneumonias. They couldn't do anything about that. We can.

Remember, too, that emergence is an evolutionary process, and that we have the ability to interfere with that process. We are facing a serious problem that will require serious intervention, but it ain’t 1918.

"Retrospective analysis suggests that a high proportion of 1918-19 deaths are attributable to bacterial pneumonias. They couldn't do anything about that. We can."

Well, we used to be able to. But overprescription of antibiotics has drastically reduced the effectiveness of many of the old stand-bys. I wouldn't be so confident of our ability to interfere with emergent evolution.

@Cedarford, actually there are other killer viruses that use airborne transmission -- smallpox, which has been eradicated but still lives on at the CDC and in Russia, and Hanta viruses. There may be others, but these two come immediately to mind.

Oh, and apparently somebody in going through a very old desk a bunch of years ago found an envelope containing scabs removed from long ago smallpox victims. The CDC took them away. No one knows if there are other old desks with envelopes like that somewhere in Washington, London, Paris, New Delhi, or somewhere no one is thinking to look.

I repeat -- we have only seen one form of flu that killed via a cytokine storm, and that was the 1918 version. People are watching for the next one but there's hardly anything you can do about it ahead of time. Flu vaccines have to be very closely tailored to the strain, and there's no way to know how any of the known strains -- swine flu, avain flu, whatever -- will mutate or when the mutation will make them go rogue.

@kynefski, I'm not sure where you got your data, but the data I'm familiar with says that the 1918 flu killed directly, through a cytokine storm. The indicator for that is that the 1918 flu preferentially killed the strong and the healthy, even among the civilian population. Bacterial pneumonia kills the very young, the very old, and the weak.

Of course some fraction of the people vaccinated with any flu vaccine get a mild case of that flu, and if the flu in question is a killer, then you start dealing with an ethical issue, don't you? I'd like to see bioethicists debate in public what fraction of the population dying from the vaccine itself is "acceptable."

But overprescription of antibiotics has drastically reduced the effectiveness of many of the old stand-bys.Much of our resistance problems have arisen from appropriate use of antibiotics. It's just a price of doing business with the bastards. In any event, we still do pretty good with community-acquired pneumonias.

...the 1918 flu killed directly, through a cytokine storm. The indicator for that is that the 1918 flu preferentially killed the strong and the healthy, even among the civilian population.The only thing I'd argue with is directly. The strong and healthy were compromised as you say.

Of course some fraction of the people vaccinated with any flu vaccine get a mild case of that flu...Only because the vaccine is weak. It is also inactivated.

@Zachery, what's sad is when people can't make fun of a president anymore. People have made fun of Ike's golf habits, LBJ's showing off his scar, Nixon's jowls, and Clinton's rabbit-like mating habits. Even the sainted Jack Kennedy had to put up with Vaughn Meador's comedy album.

@kynefski, could you clarify your source? All of the evidence I've seen indicates that secondary infections were not the killer in the 1918 pandemic.

And "inactive" or not, the fact remains that a small fraction of the people vaccinated against a strain of flu actually come down with that strain of flu. Given the current hysteria about inoculations causing autism, I can't wait to see the debate when we're talking about a rogue form of flu that kills.

The hypothesis is consistent with the observation that deaths were disproportionately among the young and healthy, and with the "cytokine storm" model. If those patients were more likely to experience a damaging inflammatory response, that would make them more susceptible to bacterial pneumonia.

The best way to follow this story is through the CDC itself:

http://cdc.gov/swineflu/

It's what they do (although I think their slogan, Safer, Healthier People, makes it sound like they serve as a kind of USDA for alien overlords).

(I don't think "Derangement" means what ZPS thinks it means. Though I'll admit this administration frequently makes me want to hit my head against the wall.)

Anyway, from the NYTImes article on The US declaring a public health emergency,

"The outbreak in the United States comes before President Obama has his full health team in place. His nominee for health secretary, Kathleen Sebelius, has not yet been confirmed by the Senate, nor has the woman he selected to Food and Drug Administration, Margaret Hamburg, a former New York City health commissioner. Mr. Obama has not yet named anyone to run the Centers for Disease Control or the National Institutes of Health."

I didn't realize the latter. I'm a bit shocked (after so many other shocks...), in particular about the CDC-- considering that we live in a world in which the threat of a pandemic, not to mention biological terrorism, is very real. Lest I be accused of suffering from "derangement," I'm just wondering.... this is unusual for a present-day administration, so far into its term, right?

The article continues & ends,

'But Robert Gibbs, the White House press secretary, said the administration is prepared.

“I want to be very clear,” Mr. Gibbs said. “There is a team in place, and part of the team is standing behind me.”'

Maryland has zero cases and tomorrow the state is opening an emergency command center. State medical authorities are also telling people the arrival of the swine flu here is is inevitable. Pro-active? Or Irresponsible?

Pro-active? Or Irresponsible?I'd say pro-active. If, in a month, everybody is really pissed at public health authorities for their ridiculous over-reaction, they will know that they have done their job.

Meanwhile, we should all take what responsibility we can. That means all you over-achievers out there who think that your work is critical and that the world cannot get by without you: You feel sick? You stay home. GOT IT?

At 56 I'm old enough to remember Legionnaire's Disease, The Great Heterosexual Aids Scare, SARS, the ebola virus, the Shark Attack Summer of 2004, and Anthrax. In all these cases a few deaths (in some cases, no deaths) were blown all out of proportion by the headline-seeking, hysteria-producing mass media. None of these ever came to pass. In many cases the total death toll was less than we routinely accept from car accidents during Labor Day Weekend.

In the cemetery behind my house, there is an area about as big as a living room with only one small stone. The inscription reads: "In memory of all the infants who died in the epidemic during the winter of 1918-19."

My grandfather (who was born in 1874) told stories about the 1918 epidemic. Two things I remember were that people put a black wreath on the door to signify someone had died from the flu; also that families who were especially striken were kept busy in the barn building coffins until all members were ill or had died.

In 2006 there was an interesting PBS documentary on the subject called Influenza 1918.

In order not to alarm the public we have rewriten our article to remove any inference that Team Obama has no one in charge of the National Health.

New article:http://www.nytimes.com/2009/04/27/world/27flu.html?ref=us

The NYTime article used to say this:

"The outbreak in the United States comes before President Obama has his full health team in place. His nominee for health secretary, Kathleen Sebelius, has not yet been confirmed by the Senate, nor has the woman he selected to Food and Drug Administration, Margaret Hamburg, a former New York City health commissioner. Mr. Obama has not yet named anyone to run the Centers for Disease Control or the National Institutes of Health."

I didn't realize the latter. I'm a bit shocked (after so many other shocks...), in particular about the CDC-- considering that we live in a world in which the threat of a pandemic, not to mention biological terrorism, is very real. Lest I be accused of suffering from "derangement," I'm just wondering.... this is unusual for a present-day administration, so far into its term, right?

The article continues & ends,

'But Robert Gibbs, the White House press secretary, said the administration is prepared.

“I want to be very clear,” Mr. Gibbs said. “There is a team in place, and part of the team is standing behind me.”'

In order not to alarm the public we have rewriten our article to remove any inference that Team Obama has no one in charge of the National Health.

New article:http://www.nytimes.com/2009/04/27/world/27flu.html?ref=us

The NYTime article used to say this:

"The outbreak in the United States comes before President Obama has his full health team in place. His nominee for health secretary, Kathleen Sebelius, has not yet been confirmed by the Senate, nor has the woman he selected to Food and Drug Administration, Margaret Hamburg, a former New York City health commissioner. Mr. Obama has not yet named anyone to run the Centers for Disease Control or the National Institutes of Health."

I didn't realize the latter. I'm a bit shocked (after so many other shocks...), in particular about the CDC-- considering that we live in a world in which the threat of a pandemic, not to mention biological terrorism, is very real. Lest I be accused of suffering from "derangement," I'm just wondering.... this is unusual for a present-day administration, so far into its term, right?

The article continues & ends,

'But Robert Gibbs, the White House press secretary, said the administration is prepared.

“I want to be very clear,” Mr. Gibbs said. “There is a team in place, and part of the team is standing behind me.”'

Ugh, so not surprised. After all, didn't you hear? The meme of the day is, stupid/evil Republicans (completely out of any power to effect anything) fought pandemic preparedness! Any unpreparedness re the swine flu is to be laid at the GOP's feet! The NYT did what it had to do-- can't have any inconvenient facts conflict with the narrative...

I was more surprised to find a NYT article straightforwardly point out (rather than spinningly couch) a fact unfavorable to Obama, evincing some fault of his administration, something that might hurt his image, something to be criticized, than I am at that fact's subsequent airbrushing. I was expecting this little slip to be corrected-- once the NYTimes got the memo, of the meme to be maintained.

People with regular exposure to pigs are at increased risk of swine flu. More than 1100 people worldwide have died from swine flu since it emerged in Mexico and the US in April, according to the latest figures from the World.

For the past month, H1N1 mutations have been popping up all over the world. Organizations such as yourself, who have been the catalyst for the spread of awareness and extensive research, are important now, more than ever. We at, Disease.com (a site dedicated to to disease treatments and preventions), are inspired by the great work by your organization, and would like to join you in the fight. If you could, please list us as a resource or host our social book mark button, it would be much appreciated. It is about time we get rid of this "national emergency".If you want more information on that please email me back with the subject line as your URL